Weight-Bearing Post-Fixation of Pelvic Facture: A Systematic Review.

Introduction

Over the last three decades, pelvic fracture surgery has noticeably increased worldwide due to the enhancement of healthcare for patients suffering from traumatic pelvic injury. In Belgium, the overall incidence of pelvic fractures increased from 15,8/100.000 persons per year in 1988 to 37,6/100.000 persons per year in 2018 (Herteleer et al., 2021). In Sweden, the incidence of pelvic fractures increased from 64 to 80 per 100,000 person-years from 2001 to 2016 mostly among females (74% of the overall incidence) (Lundin et al., 2021). In a Nordic country, the incidence of pelvic fracture that requires hospitalization increased from 34 – 56/100,000 person-year from 1997-2014 (Rinne et al., 2020). In France, the Incidence of pelvic fractures per 100,000 person-years increased from 17.1 in 2006 to 28.33 in 2016 with male predominance (Melhem et al., 2020). By 2030, the number of hip fracture patients is projected to be nearly 300,000 patients in the USA (Miyamoto et al., 2008). Thus, orthopedic researchers have been particularly interested in the outcome of interventions to fix pelvic fractures.

 

                                        Tile Classification of Pelvic Fracture

Pelvic fractures are caused by energy force ranging from low-energy force causing minor or isolated fractures to high-energy force causing major pelvic ring disruptions (Yoshihara & Yoneoka, 2014). Consequently, the elderly population is prone to low-energy minor pelvic ring fractures after low-impact fall (Herteleer et al., 2021) that carries poor outcomes (Ayoung-Chee et al., 2014). Currently, pelvic fractures are classified according to Tile system to Type A where the pelvic ring is stable, Type B which is partially stable including “open-book” and “bucket-handly” fractures, and Type C with a complete disruption of the posterior sacroiliac complex (Tile, 1996; Tile & Pennal, 1980). Moreover, the Young and Burgess classification system depends on computed tomographic (CT) pictures categorizing pelvic fracture into Lateral compression (LC), anteroposterior compression (ABC), vertical shear (VS), and combined (Young et al., 1986).

 

The application of post-fixation weight-bearing in the rehabilitation of patients who carried out pelvic fracture fixation surgery is a challenging topic. The current consensus is that no weight-bearing or toe-touch weight-bearing should be practiced as an early therapeutic approach in patients with unstable pelvic fractures (Murena et al., 2021). According to the American Academy of Orthopedic Surgeons (AO), an interval of 10-12 weeks should elapse before the initial graduation of weight bearing by a 25% increment per week (Roberts et al., 2015). Moreover, for rotationally unstable but vertically stable pelvic fractures, the recommendation of the British and Irish surgeon consultants was against early weight-bearing that should be delayed for 8-12 weeks postoperatively (Gill et al., 2017). The rationale for delaying weight bearing is based on the empirical knowledge of experts practicing post-fixation pelvic fracture surgery for years (Kalmet et al., 2018). The main concern is centered around the reduction of shearing forces at the site of the fracture to promote bone and ligament healing, reduction of implant failure risk, fear of fracture displacement, and avoidance of malunion or nonunion (Eickhoff et al., 2022; Paulsson et al., 2021).

 

On the other hand, it is theorized that early weight-bearing of post-fixation pelvic fracture surgery provides valuable benefits including maintaining bone stock and muscle mass, preserving the range of movement, and improving rehabilitation as per the patients’ goals (Poole et al., 2022). Moreover, early weight bearing would minimize the incidence of venous thromboembolism (VTE) (Dwyer & Moed, 2019; Nelson et al., 2020) and pulmonary embolism (PE) (Kim et al., 2021) in post-operative bed-ridden patients. Furthermore, it was concluded that compliance with weight-bearing is low among the aged population more than 65 years as well as weight-bearing education (Seo et al., 2020). In addition, early weight bearing shortens the period to return to work with the reduction of the cost burden (Kubiak et al., 2013). However, the scientific evidence base to make recommendations is lacking (Rickman et al., 2019).

 

To apply unrestricted weight-bearing of post-fixation pelvic surgery, evidence of the safety and efficacy of the weight-bearing approach should be established. Loss of reduction that mandates reoperation is the main concern of the weight-bearing debate. Therefore, the current study reviewed all post-fixation pelvic fracture surgery patients who carried out the weight-bearing approach from 2017 to 2022. The main aim of the study was to assess the safety of the weight-bearing approach. In addition, this review was carried out to explore the indications for weight-bearing in post-fixation pelvic fracture surgery to emphasize and detect clinical evidence for practical recommendations supporting the weight-bearing approach.  

 

Methods

 The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement guidelines (Moher et al., 2009) were followed throughout the processing stages of this study. The processing stages were performed according to the Cochrane Handbook for Systematic Reviews of Interventions (Higgins, 2003).

 

Eligibility Criteria 

Studies were included according to the following criteria: (1) adult participants more than 18 years of age suffering from a pelvic fracture that mandates operative intervention; (2) the study design could be double arm designs, randomized controlled trials (RCTs), case studies and case series, clinical trials, and case-control studies; (3) Studies published in English; (4) studies from 2017-2022; (5) studies focusing on or including rotationally unstable but vertically stable pelvic fracture (Tile classification: Type B pelvic fracture); (6) studies that adopt early weight bearing as post-fixation therapy for a minimum period of 6 months at least.

Moreover, we excluded studies carried out on patients less than 18 years of age, study designs including conferences, abstracts, unpublished preprint studies data, editorial letters, and studies written in a language other than English.

 

Outcomes

The outcomes were attributed to reported results either formal outcome scores or descriptive discourse with a minimum follow-up of 6 months. The primary outcomes were the quality of life and pain within 6 weeks of post-operative weight-bearing following a pelvic fracture. In addition, post-operative weight-bearing regimens were recorded and included in the review as a secondary outcome. No comparison was carried out between the weight-bearing regimen in this study.

 

Endpoints

The endpoints included the endpoint of the study follow-up. The follow-up periods were recorded and reviewed as well.  

 

Search Strategy and Study Selection

Using relevant keywords, the databases PubMed, Scopus, Cochrane, Web of Science, Embase, and Science Direct were searched. The recent papers from 2017 to 2022 were identified and selected. The used search terms include “fracture pelvis,” “pelvic trauma,” pelvic ring fracture,” pelvis fracture,” and “pelvic fracture.” Other search terms were used to meet the aim of the study including “weight-bearing,” fixation,” and “post-operative fixations.”  Mesh terms were used when applicable. Wild cards and operators including “AND”, “OR”, and “NOT” were used when necessary to fine-tune the research.

The search results were screened independently by two researchers. Study selection was based on the eligibility criteria. Exclusion of the study relied first on the paper’s title then the abstract and followed by full-text screening. The bibliographic references of the included studies were also manually screened to find any other eligible studies that may have been missed from previous stages. Data were extracted and collected in an electronic spreadsheet for further processing. The extracted data included the demographic information, age, sex, type of pelvic fracture, the weight-bearing regimen, the duration of follow-up and weight-bearing, and the reported results after the application of the weight-bearing regimen whether in a score format or descriptive discourse.  In case of disagreement between the two researchers, a third researcher acted to resolve any disagreements between the other two researchers.

 

Quality Assessment

 

Data Extraction

Data was obtained from texts and tables, and supplementary data. We focused on the outcomes of the application of weight-bearing post-fixation of pelvic injury.

 

Results

Study selection

Strict research was conducted on the pre-set databases using the keywords, the time limitations, and the article language to minimize the number of collected articles. Primarily, database research generated 485 articles out of which 73 were duplicates. The records were examined by title and abstract leading to the exclusion of 393 leaving 19 articles for retrieval. Four files were not retrieved and only 15 articles were assessed for eligibility. After reviewing the whole article, nine articles were excluded because they were not studying pelvic fracture. Finally, 6 articles were included in the review (Figure 1).

 

Study characteristics

The characterization of the eligible papers were summarized in Table 1. Five studies adopted the retrospective research design and one study was a randomized controlled trial (RCT). The RCT study was presented with two sets of data. The 6 retrospective studies enrolled 239 patients. In one study, the number of male and female participants could not be retrieved. The number of males in the remaining 5 articles (n=198) was 127 and the females were 71 participants. Tile (n=4) and Young and Burgess (n=2) classifications were used in 5 studies. The pelvic fracture was classified into acetabular and pelvic fractures in one study. All participants had undergone internal fixations with different procedures. 

Risk of Bias

Primary outcomes

Pain

The pain was assessed differently in 4 articles (5 datasets) only. One study used pain control metrics including the need for paracetamol and opioids (Moussa et al., 2022). In the first dataset (anteroposterior-reduction), the pain control metric showed 50% use for both paracetamol and opioids respectively. In the second dataset (posterior reduction), the pain control metric was 60% and 40% for paracetamol and opioids respectively.

 

The second study used Majeed scores that includes pain assessment, 30 points (Wang et al., 2022). The study concluded a significant reduction of pain means of the Visual Analogue scale VAS score from 7:47 ± 1:54 pre-operatively to 4:06 ± 1:32 post-operatively.

 

The third study used the pain VAS score to assess pain as well as the need for analgesics  (Benhenneda et al., 2022). Pain mean VAS scores improved from 4.1±0.63 preoperatively to 0.9 ±0.25 postoperatively with a significant difference (P<0.0001). The mean dose of morphine consumption for pain was reduced from 5.7± 0.76 mg/d (preoperatively) to 1.6±1.09 mg/d (postoperatively). The mean dose of paracetamol consumption was reduced from 2.2±0.59 g/d (preoperatively) to 1.3±0.40 g/d (postoperatively) with no significant difference (P > 0.05). The fourth study used the percentage (Kezunovic & Bulatovic, 2019). The percentage of patients with pain was 19% (n=41).

 

 

Quality of life

The quality of life was not measured directly in any study. However, 2 studies provided data that could reflect the quality of life. The first study used the Majeed score (Majeed, 1989) as an assessment tool for evaluating the clinical and functional outcomes including pain (30 points), standing (36 points), sitting (10 points), sexual function (4 points), and walking (20 points). The excellent and good scores were 87.5% (Wang et al., 2022). 

The second study utilized a set of data to analyze the clinical and functional outcomes (Kezunovic & Bulatovic, 2019) including pain (19%), activities (87%), range of motion (63%), and power (94%) according to the Modified Merle d'Aubigné and Postel scoring system (Øvre et al., 2005).

 

Secondary outcomes

post-operative weight-bearing protocols

All six studies allowed early weight bearing with different protocols. One study allowed full weight bearing in 22 cases (Wang et al., 2022). Three studies allowed immediate weight bearing as tolerated (Poole et al., 2022; Kankanalu et al., 2021; Benhenneda et al., 2022). Another study allowed partially assisted mobilization for 6 months (Moussa et al., 2022). One study adopted early mobilization without providing details (Kezunovic & Bulatovic, 2019). 

Discussion

The context of the study

The current study reviewed the outcomes of pain and quality of life in patients with post-fixation Tile type-B pelvic fractures (rotationally unstable but vertically stable pelvic fractures) who were allowed to early weight-bearing. The review of the literature revealed that pain was assessed differently across the studies. Generally, early weight-bearing in these subsets of patients showed marked improvement in pain scores irrespective of the assessment tools. Moreover, the need for analgesia postoperatively was markedly reduced. The quality of life was not directly measured in the retrieved studies. However, other tools including Majeed (Majeed, 1989) and Merle d'Aubigné and Postel scoring were used to assess the clinical and functional outcomes that can reflect indirectly the quality of life. Based on these tools, the clinical and functional outcomes showed marked improvement in patients who were allowed to have early weight-bearing. The early weight-bearing regimens were variable among the studies as well as the corresponding pelvic fixation operation.

 

Agreement and disagreement with the literature

Concerning pain reduction, recent systematic reviews concluded that pain was not used as an assessment parameter to evaluate early weight-bearing post-fixation of pelvic fracture (Murena et al., 2021) (Rickman et al., 2019). One systematic review stated that pain was used as a non-validated clinical outcome measure with no further details (Rickman et al., 2019). On the contrary, according to the results of this review, the pain was the major outcome in the included studies with positive results. Moreover, analgesic requirement rates were considered as an additional parameter to the standard pain scale.

 

The quality of life was not considered directly in literature considering early weight-bearing post-fixation of pelvic fracture. However, Richman and colleagues (2019) reported that the clinical and functional outcomes were measured using the Majeed (Majeed, 1989) or the modified Lindahl version (Lindahl et al., 1999) in 19.7% (n=24) of the eligibly reviewed studies while only 8.2% (n=10) of the studies used SF-36 score that measures the health-related quality of life. The outcome of these measures was promising for early weight-bearing (Rickman et al., 2019). In addition, clinical and functional outcomes were assessed with a modified d’Aubignè Score and Short Musculoskeletal Function Assessment yielding excellent results (Kazemi & Archdeacon, 2012). In this review, the Majeed score (Majeed, 1989) and Modified Merle d'Aubigné and Postel scoring system (Øvre et al., 2005) were utilized. In agreement with the literature, the clinical and functional outcomes yielded good results.

 

This study was comparable to the literature regarding the use of different weight-bearing regimens. However, the comparison between the different weight-bearing regimen protocols was not conducted throughout the literature from the inception of the data based up to the time of conducting this study (Murena et al., 2021) (Rickman et al., 2019). Herein, the different weight-regimen protocols were stated without comparison.

 

It is worth noting that a few number of studies had been added since the older review studies were published about early weight-bearing after post-fixation of unstable pelvic fracture (Murena et al., 2021) (Rickman et al., 2019). Early weight-bearing decision-making is influenced by several factors such as fracture type, osteosynthesis, concurrent traumas, concurrent diseases, and implant problems.(Gortler et al., 2018; Hernandez et al., 2012). The fear of the loss of reduction, fracture displacement, and poor post-fixation outcomes is the main reason for the reluctance of orthopedic surgeons to encourage early weight-bearing (Seo et al., 2020). Moreover, if there is a substantial probability of surgical failure in one group, an ethical concern arises, thus preventing patients’ randomization (Rickman et al., 2019).

 

Strengths and limitations

The findings of this study came from a sizable sample of patients that were used to draw these conclusions. Furthermore, to the knowledge of the author, this is the only study that addressed the pain and the quality of life (clinical and functional assessment) as the primary outcome of early weight-bearing post-fixation of pelvic fracture Tile type-B.

 

The main limitation of this review is that there is no prospective or comparative cohort study. The studies conducted within the timeframe of the study were retrospective. The only included RCT compared the outcomes of two surgical approaches not early weight-bearing against late weight-bearing. Therefore, direct evidence cannot be delineated to help decision-making by the treating surgeon.

 

implementation of the study

The encouraging findings from this review should motivate further research to precisely identify the rationale and limitations of early weight-bearing in patients with rotationally unstable but vertically stable pelvic fractures. The recognition of the intrinsic stability of the pelvic fracture, the appropriate fixation technique, and the associated morbidities should be the basis for the decision of early weight-bearing of post-fixation of pelvic fracture.

 

 

Conclusion

Early weight-bearing has many benefits in the context of Tile type-B pelvic fracture fixation. Reduction of pain and the dose of analgesic medications are the promising outcome. Moreover, the functional and clinical outcomes showed marked improvement as well. In addition,

Early weight-bearing after Tile B pelvic fixation has the potential to protect patients from bone and muscle loss, joint stiffness, and early recovery with a short hospital stay. Therefore, early weight-bearing was proposed to be advantageous in cases of stable and partially unstable pelvic fractures as well as acetabular fractures. However, the evidence-based protocol is a challenge. Further research is needed to delineate the appropriate early weight-bearing protocol corresponding to the type of pelvic fixation operation. Prospective and cohort studies are recommended for early weight-bearing decision-making.

 

 

References

 

Ayoung-Chee, P., McIntyre, L., Ebel, B. E., Mack, C. D., McCormick, W., & Maier, R. V. (2014). Long-term outcomes of ground-level falls in the elderly. The Journal of Trauma and Acute Care Surgery, 76(2), 498–503; discussion 503. https://doi.org/10.1097/TA.0000000000000102

Benhenneda, R., Letissier, H., Dubrana, F., & Di Francia, R. (2022). Immediate full weight bearing after pelvic percutaneous fixation by screw for simple acetabular and pelvic ring fractures in patients older than sixty five years. International Orthopaedics, 46(10), 2413–2421. https://doi.org/10.1007/s00264-022-05504-z

Bruce, B., Reilly, M., & Sims, S. (2011). OTA highlight paper predicting future displacement of nonoperatively managed lateral compression sacral fractures: Can it be done? Journal of Orthopaedic Trauma, 25(9), 523–527. https://doi.org/10.1097/BOT.0b013e3181f8be33

Court-Brown, C. M., & Caesar, B. (2006). Epidemiology of adult fractures: A review. Injury, 37(8), 691–697. https://doi.org/10.1016/j.injury.2006.04.130

Dwyer, E. P., & Moed, B. R. (2019). Venous thromboembolism after hospital discharge in pelvic and acetabular fracture patients treated operatively. Journal of Orthopaedic Surgery (Hong Kong), 27(1), 2309499019832815. https://doi.org/10.1177/2309499019832815

Eickhoff, A. M., Cintean, R., Fiedler, C., Gebhard, F., Schütze, K., & Richter, P. H. (2022). Analysis of partial weight bearing after surgical treatment in patients with injuries of the lower extremity. Archives of Orthopaedic and Trauma Surgery, 142(1), 77–81. https://doi.org/10.1007/s00402-020-03588-z

Gill, J. R., Murphy, C., Quansah, B., & Carrothers, A. (2017). Management of the open book APC II pelvis: Survey results from pelvic and acetabular surgeons in the United Kingdom. Journal of Orthopaedics, 14(4), 530–536. https://doi.org/10.1016/j.jor.2017.08.004

Gortler, H., Rusyn, J., Godbout, C., Chahal, J., Schemitsch, E. H., & Nauth, A. (2018). Diabetes and Healing Outcomes in Lower Extremity Fractures: A Systematic Review. Injury, 49(2), 177–183. https://doi.org/10.1016/j.injury.2017.11.006

Green, S., Higgins, P., alderson, P., Clarke, M., Mulrow, D. C., & Oxaman. (2011). Cochrane Handbook: Cochrane Review: Ch 8: Assessing risk of bias in included studies. In Cochrane Handbook for: Systematic Reviews of Interventions (Vol. 6, pp. 3–10).

Hernandez, R. K., Do, T. P., Critchlow, C. W., Dent, R. E., & Jick, S. S. (2012). Patient-related risk factors for fracture-healing complications in the United Kingdom General Practice Research Database. Acta Orthopaedica, 83(6), 653–660. https://doi.org/10.3109/17453674.2012.747054

Herteleer, M., Dejaeger, M., Nijs, S., Hoekstra, H., & Laurent, M. R. (2021). Epidemiology and secular trends of pelvic fractures in Belgium: A retrospective, population-based, nationwide observational study. Bone, 153, 116141. https://doi.org/10.1016/j.bone.2021.116141

Higgins, J. P. T. (2003). Measuring inconsistency in meta-analyses. BMJ, 327(7414), 557–560. https://doi.org/10.1136/bmj.327.7414.557

Kalmet, P. H. S., Meys, G., V Horn, Y. Y., Evers, S. M. A. A., Seelen, H. A. M., Hustinx, P., Janzing, H., Vd Veen, A., Jaspars, C., Sintenie, J. B., Blokhuis, T. J., Poeze, M., & Brink, P. R. G. (2018). Permissive weight bearing in trauma patients with fracture of the lower extremities: Prospective multicenter comparative cohort study. BMC Surgery, 18(1), 8. https://doi.org/10.1186/s12893-018-0341-3

Kankanalu, P., Orfanos, G., Dwyer, J., Lim, J., & Youssef, B. (2021). Can locking plate fixation of symphyseal disruptions allow early weight bearing? Injury, 52(10), 2725–2729. https://doi.org/10.1016/j.injury.2020.02.094

Kim, J. H., Lim, H., Kim, H. M., & Lim, J. A. (2021). Intraoperative development of pulmonary thromboembolism in a bedridden patient owing to a pelvic bone fracture with negative preoperative computed tomography pulmonary angiographic findings: A case report. Medicine, 100(29), e26658. https://doi.org/10.1097/MD.0000000000026658

Kubiak, E. N., Beebe, M. J., North, K., Hitchcock, R., & Potter, M. Q. (2013). Early Weight Bearing After Lower Extremity Fractures in Adults: Journal of the American Academy of Orthopaedic Surgeons, 21(12), 727–738. https://doi.org/10.5435/JAAOS-21-12-727

Langford, J. R., Burgess, A. R., Liporace, F. A., & Haidukewych, G. J. (2013). Pelvic fractures: Part 2. Contemporary indications and techniques for definitive surgical management. The Journal of the American Academy of Orthopaedic Surgeons, 21(8), 458–468. https://doi.org/10.5435/JAAOS-21-08-458

Lee, K. H., Kim, J. Y., Yim, S. J., Moon, D. H., Choi, G. H., & Moon, K. H. (2014). Incidence and risk factors of subsequent hip fractures in Korea: Multicenter study. Journal of Korean Medical Science, 29(7), 992–994. https://doi.org/10.3346/jkms.2014.29.7.992

Lundin, N., Huttunen, T. T., Berg, H. E., Marcano, A., Felländer-Tsai, L., & Enocson, A. (2021). Increasing incidence of pelvic and acetabular fractures. A nationwide study of 87,308 fractures over a 16-year period in Sweden. Injury, 52(6), 1410–1417. https://doi.org/10.1016/j.injury.2021.03.013

Melhem, E., Riouallon, G., Habboubi, K., Gabbas, M., & Jouffroy, P. (2020). Epidemiology of pelvic and acetabular fractures in France. Orthopaedics & Traumatology, Surgery & Research: OTSR, 106(5), 831–839. https://doi.org/10.1016/j.otsr.2019.11.019

Miyamoto, R. G., Kaplan, K. M., Levine, B. R., Egol, K. A., & Zuckerman, J. D. (2008). Surgical management of hip fractures: An evidence-based review of the literature. I: femoral neck fractures. The Journal of the American Academy of Orthopaedic Surgeons, 16(10), 596–607. https://doi.org/10.5435/00124635-200810000-00005

Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & The PRISMA Group. (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Medicine, 6(7), e1000097. https://doi.org/10.1371/journal.pmed.1000097

Murena, L., Canton, G., Hoxhaj, B., Sborgia, A., Fattori, R., Gulli, S., & Vaienti, E. (2021). Early weight bearing in acetabular and pelvic fractures. Acta Bio-Medica: Atenei Parmensis, 92(4), e2021236. https://doi.org/10.23750/abm.v92i4.10787

Nelson, J. T., Coleman, J. R., Carmichael, H., Mauffrey, C., Vintimilla, D. R., Samuels, J. M., Sauaia, A., & Moore, E. E. (2020). High Rate of Fibrinolytic Shutdown and Venous Thromboembolism in Patients With Severe Pelvic Fracture. The Journal of Surgical Research, 246, 182–189. https://doi.org/10.1016/j.jss.2019.09.012

Önsten, I., Berzins, A., Shott, S., & Sumner, D. R. (2001). Accuracy and precision of radiostereometric analysis in the measurement of THR femoral component translations: Human and canine in vitro models. Journal of Orthopaedic Research, 19(6), 1162–1167. https://doi.org/10.1016/S0736-0266(01)00039-0

Paulsson, M., Ekholm, C., Jonsson, E., Geijer, M., & Rolfson, O. (2021). Immediate Full Weight-Bearing Versus Partial Weight-Bearing After Plate Fixation of Distal Femur Fractures in Elderly Patients. A Randomized Controlled Trial. Geriatric Orthopaedic Surgery & Rehabilitation, 12, 21514593211055890. https://doi.org/10.1177/21514593211055889

Poole, W. E. C., Neilly, D. W., & Rickman, M. S. (2022). Is unrestricted weight bearing immediately after fixation of rotationally unstable pelvic fractures safe? BMC Musculoskeletal Disorders, 23(1), 348. https://doi.org/10.1186/s12891-022-05299-5

Rickman, M., Link, B.-C., & Solomon, L. B. (2019). Patient Weight-bearing after Pelvic Fracture Surgery—A Systematic Review of the Literature: What is the Modern Evidence Base? Strategies in Trauma and Limb Reconstruction, 14(1), 45–52. https://doi.org/10.5005/jp-journals-10080-1414

Rinne, P. P., Laitinen, M. K., Kannus, P., & Mattila, V. M. (2020). The incidence of pelvic fractures and related surgery in the Finnish adult population: A nationwide study of 33,469 patients between 1997 and 2014. Acta Orthopaedica, 91(5), 587–592. https://doi.org/10.1080/17453674.2020.1771827

Roberts, K. C., Brox, W. T., Jevsevar, D. S., & Sevarino, K. (2015). Management of Hip Fractures in the Elderly. JAAOS - Journal of the American Academy of Orthopaedic Surgeons, 23(2), 131–137. https://doi.org/10.5435/JAAOS-D-14-00432

Seo, H., Lee, G. J., Shon, H.-C., Kong, H. H., Oh, M., Cho, H., & Lee, C. J. (2020). Factors Affecting Compliance With Weight-Bearing Restriction and the Amount of Weight-Bearing in the Elderly With Femur or Pelvic Fractures. Annals of Rehabilitation Medicine, 44(2), 109–116. https://doi.org/10.5535/arm.2020.44.2.109

Sulmasy, D. P. (2019). Ethics and Evidence. The Journal of Clinical Ethics, 30(1), 56–66.

Tile, M. (1996). Acute Pelvic Fractures: I. Causation and Classification. JAAOS - Journal of the American Academy of Orthopaedic Surgeons, 4(3), 143–151.

Tile, M., & Pennal, G. F. (1980). Pelvic disruption: Principles of management. Clinical Orthopaedics and Related Research, 151, 56–64.

Xiong, B., Yang, P., Lin, T., Xu, J., Xie, Y., Guo, Y., Liu, C., Zhou, Qi., Lai, Q., He, W., Wei, Q., & Zhang, Q. (2022). Changes in hip joint contact stress during a gait cycle based on the individualized modeling method of “gait-musculoskeletal system-finite element.” Journal of Orthopaedic Surgery and Research, 17(1), 267. https://doi.org/10.1186/s13018-022-03094-5

Yoshida, H., Faust, A., Wilckens, J., Kitagawa, M., Fetto, J., & Chao, E. Y.-S. (2006). Three-dimensional dynamic hip contact area and pressure distribution during activities of daily living. Journal of Biomechanics, 39(11), 1996–2004. https://doi.org/10.1016/j.jbiomech.2005.06.026

Yoshihara, H., & Yoneoka, D. (2014). Demographic epidemiology of unstable pelvic fracture in the United States from 2000 to 2009: Trends and in-hospital mortality. The Journal of Trauma and Acute Care Surgery, 76(2), 380–385. https://doi.org/10.1097/TA.0b013e3182ab0cde

Young, J. W., Burgess, A. R., Brumback, R. J., & Poka, A. (1986). Pelvic fractures: Value of plain radiography in early assessment and management. Radiology, 160(2), 445–451. https://doi.org/10.1148/radiology.160.2.3726125

 

 

Figures

 

Figure 1: PRISMA flow diagram.

 

 

 

 

 

 

Tables

 

Table 1: the characterization of the eligible papers